Behavioral Health Site Review Survey Partnership HealthPlan of California Quality Monitoring & Improvement Department

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1 Behavioral Health Site Review Survey Partnership HealthPlan of California Quality Monitoring & Improvement Department ATTACHMENT B Review Date: Last Review Provider Address: Phone: Fax: Staff on site: MD PHD NP LCSW MFCC MSW RN LVN Clerical Contact Person/Title: Reviewer/Title: Reviewer: /Title: Visit Purpose Site-Specific Certification(s) Provider type Clinic type Initial Full Scope Monitoring AAAHC JCAHO Behavioral Health Primary Care Community Periodic Full Scope Focused Review Follow-up Ed/TA Other (type) Substance Abuse Certification NCQA Substance Abuse Non-physician Practitioner (type) Hospital FQHC Rural Health Other (type) Solo Group Staff/Teaching Site Scores Scoring Procedure Compliance Rate I. Access/Safety /8 II. Personnel /3 III. Office Management /9 IV. Clinical Management /4 Total (points given) ) Add points given in each section. 2) Add total points given for all six sections. 3) Adjust score for "N/A" criteria (if needed). Subtract N/A points from 34 total points possible. 4) Divide total points given by 34 or by adjusted total points. 5) Multiply by 00 to get the compliance (percent) rate. 6) Calculate = X 00 = % Points Total/Adjusted Decimal Compliance given Points Score Rate Exempted Pass: 90%/above (w/o critical element deficit) Conditional Pass: 80-89%, or 90% and above with deficiencies in Critical Elements Not Pass: Below 80% CAP Required Other follow-up I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Tool.doc Page of 0

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4 I. Access/Safety Site Access/Safety Survey Criteria Yes No N/A Wt Site Score A. Site is accessible and useable by individuals with physical disabilities 3 CCR 504; 24 CCR (CA Building Standards Code); 28 CFR 35 (American Disabilities Act of 990, Title II, Title III) Sites must have the following safety accommodations for physically disabled persons: Clearly marked (blue) curb or sign designating disabled-parking space near accessible primary entrance. 2 Pedestrian ramps have a level landing at the top and bottom of the ramp. 3 Exit doorway openings allow for clear passage of a person in a wheelchair. 3 4 Accessible passenger elevator or reasonable alternative for multi-level floor accommodation. 5 Clear floor space for wheelchair in waiting area and exam room. 6Wheelchair accessible restroom facilities or reasonable alternative Wheelchair accessible hand washing facilities or reasonable alternative Comments: Write comments for all No (0 points) and N/A scores. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Tool.doc Page 4 of 0

5 Site Access/Safety Survey Criteria Yes No N/A Wt. Site Score B. Site environment is maintained in a clean and sanitary condition. 8 CCR 593; 28 CCR All patient areas including floor/carpet, walls, and furniture are neat, clean and well maintained. 2 Restrooms are clean and contain appropriate sanitary supplies C. Site environment is safe for all patients, visitors and personnel. 8 CCR 3220; 22 CCR 53230; 24 CCR, 2, 3, 9; 28 CCR ; 29 CFR 90.30, There is evidence that staff has received safety training and/or has safety information available in the following: Fire safety and prevention 2 Emergency non-medical procedures (e.g. site evacuation, workplace violence) 3 Lighting is adequate in all areas to ensure safety. 4 Exit doors and aisles are unobstructed and egress (escape) accessible. 5 Exit doors are clearly marked with Exit signs. 6 Clearly diagramed Evacuation Routes for emergencies are posted in a visible location. 7 Electrical cords and outlets are in good working condition. 8 At least one type of fire fighting/protection equipment is accessible at all times Comments: Write comments for all No (0 points) and N/A scores. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Tool.doc Page 5 of 0

6 II. Personnel Site Personnel Survey Criteria Yes No N/A Wt Site Score A. Professional health care personnel have current California Licenses and Certifications. CA Business & Professional (B&P) Code 2050, 2585, 2725, 2746, 2834, 3500, 40 All required Professional Licenses and Certifications, issued from the appropriate licensing/certification agency, are current. Notification is provided to each member that the MD(s) is licensed and regulated by the Medical Board, and that the Physician Assistant(s) is licensed and regulated by the Physician Assistant Committee. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Tool.doc Page 6 of 0

7 Site Personnel Survey Criteria Yes No N/A Wt Site Score B. Scope of practice for non-physician behavioral health practitioners is clearly defined Standardized procedures define the scope of services provided by non-physician practitioners 2 Standardized procedures, Delegation of Services Agreements and Supervisory guidelines are revised, updated and signed by the supervising physician when changes in scope of services occur Comments: Write comments for all No (0 points) and N/A scores. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Tool.doc Page 7 of 0

8 III. Office Management Office Management Survey Criteria Yes No N/A Wt.Site Score A. Medical records are available for the Provider at each scheduled patient encounter. 22 CCR 75055; 28 CCR Medical records are readily retrievable for scheduled patient encounters. 2 Medical documents are filed in a timely manner to ensure availability for patient encounters. B. Confidentiality of personal medical information is protected according to State and federal guidelines. 22 CCR 5009, 5386, 75055; 28 CCR ; CA Civil Code 56.0 (Confidentiality of Medical Information Act) Behavioral health consult and therapy rooms safeguard patients right to privacy. 2 Procedures are followed to maintain the confidentiality of personal patient information. 3 Medical record release procedures are compliant with State and federal guidelines. 4 Storage and transmittal of medical records preserves confidentiality and security. 5 All licensed psychologists in California must retain a patient's health service records for a minimum of seven (7) years from the patient's discharge date or seven years after a minor patient reaches the age of eighteen. 6 There is a system in place that ensures medical records are maintained in a consistent manner I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Tool.doc Page 8 of 0

9 C. Health Care Services are readily available 22 CCR (2). Office Management Survey Criteria Yes No N/A Wt.Site Score Appointments are scheduled according to patients stated clinical needs within the timeliness standards established for plan members. 2 There is a system in place to follow- up on missed or cancelled appointments Comments: Write comments for all No (0 points) and N/A scores. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Tool.doc Page 9 of 0

10 IV. Clinical Management Pharmaceutical Services Survey Criteria Yes No N/A Wt Site Score A. Drugs and medication supplies are maintained secure to prevent unauthorized access. CA B&P Code 405.3, 407, 472; 22 CCR 75037(a-g), 75039; 2 CFR 30.75, 30.76, Drugs are stored in specifically designated cupboards, cabinets, closets or drawers. 2 Prescription, sample and over-the counter drugs, hypodermic needles/syringes, prescription pads are securely stored in a lockable space (cabinet or room) within the office/clinic. 3 Controlled drugs are stored in a locked space accessible only to authorized personnel. 4 A dose-by-dose controlled substance distribution log is maintained. 5 Emergency medical equipment appropriate to the practice site/population is available. Comments: Write comments for all No (0 points) and N/A scores. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Tool.doc Page 0 of 0

11 Site Review Guidelines Substance Abuse California Department of Health Services Medi-Cal Managed Care Division ATTACHMENT A Purpose: Site Review Guidelines provide the standards, directions, instructions, rules, regulations, perimeters, or indicators for the site review survey. These Guidelines shall be used as a gauge or touchstone for measuring, evaluating, assessing, and making decisions. Scoring: Site survey includes on-site inspection and interviews with site personnel. Reviewers are expected to use reasonable evidence available during the review process to determine if practices and systems on site meet survey criteria. Compliance levels include: ) Exempted Pass: 94% or above without deficiencies in critical elements, 2) Conditional Pass: 80-93%, or 94% and above with deficiencies in critical elements, and 3) Not Pass: below 80%. Compliance rates are based on 34 total possible points, or on the total adjusted for Not Applicable (N/A) items. N/A applies to any scored item that does not apply to a specific site as determined by the reviewer. Directions: Score full point(s) if survey item is met. Score zero (0) points if item is not met. Do not score partial points for any item. Explain all N/A and No (0 point) items in the comment section. Provide assistance/consultation as needed for corrective action plans, and establish follow-up/verification timeline. ) Add the points given in each section. 2) Add points given for all three (3) sections to determine total points given for the site. 3) Subtract all N/A items from 34 total possible points to determine the adjusted total possible points. If there are no N/A items, calculation of site score will be based on 34 points. 4) Divide the total points given by 34 or by the adjusted total. Multiply by 00 to calculate percentage rate. Scoring Example: Step : Add the points given in each section. Step 2: Add points given for all three (4) sections. 8 (Access/safety) 03 (Personnel) 09 (Office Management) 04 (Clinical Management) 34 (POINTS) Step 3: Subtract N/A points from 34 total points possible. 34 (Total points possible) 0 (N/A points) 34 ( Adjusted total points possible) Step 4: Divide total points given by 34 or by the adjusted points, then multiply by 00 to calculate percentage rate. Points given or adjusted total or 34 =. 00 =00% I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Guidelines.doc Page of 8

12 Criteria A. Site is accessible and useable by individuals with physical disabilities. Access/Safety Reviewer Guidelines ADA Regulations: Site must meet city, county and state building structure and access ordinances for persons with physical disabilities. A site/facility includes the building structure, walkways, parking lots, and equipment. All facilities designed, constructed; or altered by, on behalf of, or for the use of a public entity must be readily accessible and usable by individuals with disabilities, if the construction or alteration was begun after January 26, 992 (28 CFR 35.5). Any alteration to a place of public accommodation or a commercial facility, after January 26, 992, must be made to ensure that, to the maximum extent feasible, the altered portions of the facility are readily accessible to and useable by individuals with disabilities, including individuals who use wheelchairs (28 CFR ). Parking: Parking spaces for persons with physical disabilities are located in close proximity to handicap-accessible building entrances. Each parking space reserved for the disabled is identified by a permanently affixed reflectorized sign posted in a conspicuous place. If provider has no control over availability of disabled parking lot or nearby street spaces, provider must have a plan in place for making program services available to persons with physical disabilities. Ramps: A clear and level landing is at the top and bottom of all ramps and on each side of an exit door. Any path of travel is considered a ramp if its slope is greater than a -foot rise in 20 feet of horizontal run. Exit doors: The width of exit doorways (at least 32-in.) allows for passage clearance of a wheelchair. Exit doors include all doors required for access, circulation and use of the building and facilities, such as primary entrances and passageway doors. Furniture and other items do not obstruct exit doorways or interfere with door swing pathway. Elevators: If there is no passenger elevator, a freight elevator may be used to achieve program accessibility if it is upgraded for general passenger use and if passageways leading to and from the elevator are well-lit, neat and clean. Clear Floor Space: Clear space in waiting/exam areas is sufficient (at least 30-in. x 48-in.) to accommodate a single, stationary adult wheelchair and occupant. A minimum clear space of 60-in. diameter or square area is needed to turn a wheelchair. Sanitary Facilities: Restroom and hand washing facilities are accessible to able-bodied and physically disabled persons. A wheelchair accessible restroom stall allows sufficient space for a wheelchair to enter and permits the door to close. If wheelchair accessible restrooms are not available within the office site, reasonable alternative accommodations are provided. Alternatives may include: grab bars located behind and/or along the sides of toilet with assistance provided as needed by site personnel; provision of urinal, bedpan, or bedside commode placed in a private area; wheelchair accessible restroom located in a nearby office or shared within a building. Sufficient knee clearance space underneath the sink allows for wheelchair users to safely use a lavatory sink for hand washing. A reasonable alternative may include, but is not limited to, hand washing items provided as needed by site personnel. Note: A public entity may not deny the benefits of its program, activities, and services to individuals with disabilities because its facilities are inaccessible (28 CFR ). Every feature need not be accessible, if a reasonable portion of the facilities and accommodations provided is accessible (Title 24, Section 2-49, California Administrative Code, the State Building Code). Reasonable Portion and/or Reasonable Alternatives are acceptable to achieve program accessibility. Reasonable Portion applies to multi-storied structures and provides exceptions to the regulations requiring accessibility to all portions of a facility/site. Reasonable Alternatives are methods other than site structural changes to achieve program accessibility, such as acquisition or redesign of equipment, assignment of assistants/aides to beneficiaries, provision of services at alternate accessible sites, and/or other site specific alternatives to provide services (ADA, Title II, ). Points shall not be deducted if Reasonable Portion or Reasonable Alternative is made available on site. Specific measurements are provided strictly for reference only for the reviewer. Site reviewers are NOT expected to measure parking areas, pedestrian path of travel walkways and/or building structures on site. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Guidelines.doc Page 2 of 8

13 Criteria B. Site environment is maintained in a clean and sanitary condition. I. Access/Safety Reviewer Guidelines The physical appearance of floors/carpets, walls, furniture, patient areas and restrooms are clean and well maintained. Appropriate sanitary supplies, such as toilet tissue, hand washing soap, cloth/paper towels or antiseptic towelettes are made available for restroom use. Environmental safety includes the housekeeping or hygienic condition of the site. Clean means unsoiled, neat, tidy, and uncluttered. Well maintained means being in good repair or condition. C. Site environment is safe for all patients, visitors and personnel. Ordinances: Sites must meet city, county and state fire safety and prevention ordinances. Reviewers should be aware of applicable city and county ordinances in the areas in which they conduct reviews. Evacuation Routes: Clearly marked, easy-to-follow escape routes are posted in visible areas, such as hallways, exam rooms and patient waiting areas. The minimum clear passage needed for a single wheelchair is 36 inches along an accessible route, but may be reduced to a minimum of 32 inches at a doorway. Illumination: Lighting is adequate in patient flow working and walking areas such as corridors, walkways, waiting and exam rooms, and restrooms to allow for a safe path of travel. Access Aisle: Accessible pedestrian paths of travel (ramps, corridors, walkways, lobbies, elevators, etc.) between elements (seats, tables, displays, equipment, parking spaces, etc.) provide a clear circulation path. Means of egress (escape routes) are maintained free of obstructions or impediments to full instant use of the path of travel in case of fire or other emergency. Building escape routes provide an accessible, unobstructed path of travel for pedestrians and/or wheelchair users at all times when the site is occupied. Cords (including taped cords) or other items are not placed on or across walkway areas. Exits: Exit doorways are unobstructed and clearly marked by a readily visible Exit sign. Electrical Safety: Electrical cords are in good working condition with no exposed wires, or frayed or cracked areas. Cords are not affixed to structures, placed in or across walkways, extended through walls, floors, and ceiling or under doors or floor coverings. Extension cords are not used as a substitute for permanent wiring. All electrical outlets have an intact wall faceplate. Sufficient clearance is maintained around lights and heating units to prevent combustible ignition. Fire Fighting/Protection Equipment: There is fire fighting/protection equipment in an accessible location on site at all times. An accessible location is reachable by personnel standing on the floor, or other permanent working area, without the need to locate/retrieve step stool, ladder or other assistive devises. At least one of the following types of fire safety equipment is on site: ) Smoke Detector with intact, working batteries 2) Fire Alarm Device with code and reporting instructions posted conspicuously at phones and employee entrances 3) Automatic Sprinkler System with sufficient clearance (0-in.) between sprinkler heads and stored materials. 4) Fire Extinguisher in an accessible location that displays readiness indicators or has an attached current dated inspection tag. Note: Specific measurements are provided strictly for reference only for the reviewer. Site reviewers are NOT expected to measure parking areas, pedestrian path of travel walkways and/or building structures on site. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Guidelines.doc Page 3 of 8

14 Criteria A. Professional health care personnel have current California licenses and certifications. II. Personnel Reviewer Guidelines Medical Professional License/Certification Issuing Agency Doctor of Medicine Physician s & Surgeon s Certificate DEA Registration Medical Board of CA Drug Enforcement Administration Psychiatrist Physician s & Surgeon s Certificate with Medical Board of California specialty training Nurse Practitioner (NP) RN License w/np Certification and CA Board of Registered Nursing Furnishing Number Registered Nurse (RN) RN License CA Board of Registered Nursing Physicians Assistant (PA) PA License. Medical Board of CA DEA Registration DEA Marriage and Family Counselor MFCC Board of Behavioral Sciences Licensed Clinical Social Worker LCSW Board of Behavioral Sciences Behavioral Health Specialist Certificate Psychiatric Technician Psychiatric Technician CA Board of Vocational Nursing and Psychiatric Technicians Licensed Vocational Nurse (LVN): LVN License CA Board of Vocational Nursing and Psychiatric Technicians Note: All medical professional licenses and certifications must be current and issued from the appropriate agency for practice in California. Any license/certification that has been approved during the current re/credentialing process need not be re-checked during the site review. Any licenses/certifications not included in the re/credentialing process must be checked for current status as part of the site review process. Although sites with centralized personnel departments are not required to keep documents or copies on site, copies and/or lists of currently certified or credentialed personnel must be readily available when requested by reviewers. Note: Effective June 27, 200, per CCR, Title 6, 355.4, mandated by Business and Professions Code section 38, MDs (does not apply to Osteopaths) shall provide notification to each patient that states the MD(s) on site is licensed and regulated by the Board, and includes the following: NOTICE Medical doctors are licensed and regulated by the Medical Board of California (800) Note: Effective August, 20, per CCR, Title 6, , mandated by Business and Professions Code section 38, PAs shall provide notification to each patient that states the PA(s) is licensed and regulated by the Physician Assistant Committee, and includes the following: NOTIFICATION TO CONSUMERS Physician Assistants are licensed and regulated by the Physician Assistant Committee (96) I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Guidelines.doc Page 4 of 8

15 Criteria B. Scope of practice for nonphysician medical provider (NPMP) is clearly defined. II. Personnel Reviewer Guidelines Reviewers are expected to verify that NP and PA Delegation of Services Agreement and Supervision Physician s Responsibility documentation are present on site. Reviewers are not expected to make in-depth evaluation of appropriateness of the NPMP s scope of practice. Documents may be utilized to determine and/or clarify practice procedures and supervisory processes on site.. Nurse Practitioners (NP): Nurse practitioners are prepared through education and experience to provide primary care and to perform advanced procedures. The extent of required supervision must be specified in the Standardized Procedures. Physician Assistants (PA): Every PA is required to have the following documents: ) Delegation of Services Agreement: Defines specific procedures identified in practice protocols or specifically authorized by the supervising physician, and must be dated and signed by physician and PA. An original or copy must be readily accessible at all practice sites in which the PA works. There is no established time period for renewing the Agreement, but it is expected that the Agreement will be revised, dated and signed whenever any changes occur. Failure to maintain a Delegation of Services Agreement is a violation of the Physician Assistant Regulations and is grounds for disciplinary action by the Medical Board of California against a physician assistant s licensure. 2) Approved Supervising Physician s Responsibility for Supervision of Physician Assistants Agreement: Defines supervision responsibilities and methods required by Title 6, section of the Physician Assistant Regulations, and is signed by the physician. The following procedures must be identified: a) Transport and back-up procedures for when the supervising physician is not on the premises. b) One or more methods for performing medical record review by the supervising physician: c) Responsibility for physician review and countersigning of medical records d) Responsibility of the PA to enter the name of approved supervising physician responsible for the patient on the medical record. Note: Standardized procedures legally define the expanded scope of nursing practice that overlaps the practice of medicine. NPs operate under written Standardized Procedures that are collaboratively developed and approved by the supervising physician, the NP and administration within the organized health care facility/system in which standardized procedures will be used. Standardized Procedures should identify the furnishing of drugs or devices, extent of physician or surgeon supervision, method of periodic review of competence, including peer review, and review of provisions in the Standardized Procedures. Standardized Procedures shall undergo periodic review, with signed, dated revisions completed at each change in scope of work. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Guidelines.doc Page 5 of 8

16 Criteria A. Medical records are available for the Provider at each scheduled patient encounter. III. Office Management Reviewer Guidelines The process/system established on site provides for the availability of medical records, including outpatient, inpatient, referral services, and significant telephone consultations for patient encounters. Medical records are filed that allows for ease of accessibility within the facility, or in an approved health record storage facility off the facility premises (22 CCR, 75055). B. Medical record confidentiality is maintained according to State and Federal guidelines. Privacy: Patients have the right to privacy for dressing/undressing, physical examination and medical consultation. Practices are in place to safeguard patient privacy. Because dressing areas and examination room configurations vary greatly, reviewers will make site-specific determinations. Confidentiality: Personnel follow site policy/procedures for maintaining confidentiality of individual patient information. Individual patient conditions or information is not discussed in front of other patients or visitors, displayed or left unattended in reception and/or patient flow areas. Electronic records: Electronic record-keeping system procedures have been established to ensure patient confidentiality, prevent unauthorized access, authenticate electronic signatures, and maintain upkeep of computer systems. Security protection includes an offsite backup storage system, an image mechanism with the ability to copy documents, a mechanism to ensure that recorded input is unalterable, and file recovery procedures. Confidentiality protection may also include use of encryption, detailed user access controls, transaction logs, and blinded files. Record release: Medical records are not released without written, signed consent from the patient or patient s representative, identifying the specific medical information to be released. The release terms, such as to whom records are released and for what purposes, should also be described. This does not prevent release of statistical or summary data, or exchange of individual identifiable medical information between individuals or institutions providing care, fiscal intermediaries, research entities and State or local official agencies. Record retention: Hospitals, acute psychiatric hospitals, skilled nursing facilities, primary care clinics, psychology and psychiatric clinics must maintain medical records and exposed x-rays for a minimum of 7 years following patient discharge, except for minors (Title 22, CCR, and Section 75055). Records of minors must be maintained for at least one year after a minor has reached age 8, but in no event for less than 7 years (Title 22, CCR, and Section 75055). Each Plan must maintain all records and documentation (including medical records) necessary to verify information and reports required by statute, regulation or contractual obligation for 5 years from the end of the fiscal year in which the Plan contract expires or is terminated (Title 22, CCR, Section 5386). Adequacy of Medical Record/treatment record keeping: The reviewers must discuss office documentation practices with the practitioner or practitioner staff. This discussion must include the forms and methods used to keep the information in a consistent manner. It must also include how the practice insures the confidentiality of records. The reviewers must assess the record for orderliness of the record and documentation practices. To ensure member confidentiality the reviewer may review blinded medical/treatment records or a model instead of an actual record. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Guidelines.doc Page 6 of 8

17 C. Health Care Services are readily available The process established on site provides timely access to appointments for routine care, urgent care, and emergency care. An organized system must be clearly evident (in use) for scheduling appointments appropriately, notifying and reminding members of scheduled appointments, and following up of missed or canceled appointments. Systems, practices and procedures used for making services readily available to patients will vary from site to site. Note: The Medi-Cal Managed Care Health Plans have accepted the following timeliness standards for access to appointments: Urgent Care: 24 hours; Non-Urgent Care: 4 days; Missed and/or canceled appointments, and contact attempts must be documented in the patient s medical record. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Guidelines.doc Page 7 of 8

18 Criteria IV. Clinical Management: Pharmaceutical Services Reviewer Guidelines A. Drugs and medication supplies are maintained secured to prevent unauthorized access. Deficiencies: All deficiencies related to Pharmaceutical Services (e.g. medication maintenance, storage, safety, distribution, etc.) must be addressed in a corrective action plan. Controlled substances: Written records are maintained of controlled substances inventory list(s) that includes: provider s DEA number, name of medication, original quantity of drug, dose, date, name of patient receiving drug, name of authorized person dispensing drug, and number of remaining doses. Controlled substances are stored separately from other drugs in a securely locked, substantially constructed cabinet (Control Substances Act, CFR 30.75). Control substances include all Schedule I, II, III, IV, and V substances listed in the CA Health and Safety Code, Sections , and do not need to be double locked. Personnel with authorized access to controlled substances include physicians, dentists, podiatrists, physician s assistants, licensed nurses and pharmacists. Security: All drugs for dispensing are stored in an area that is secured at all times (CA B&P Code, 405.3). Keys to locked storage area are available only to staff authorized by the physician to have access (6 CCR, Chapter 2, Division 3, Section ). The Medical Board of California interprets all drugs to also include both sample and over-the-counter drugs. The Medical Board defines area that is secure to mean a locked storage area within a physician s office. Note: During business hours, the drawer, cabinet or room containing drugs, medication supplies or hazardous substances may remain unlocked only if there is no access to area by unauthorized persons. Whenever drugs, medication supplies or hazardous substances are unlocked, authorized clinic personnel must remain in the immediate area at all times. At all other times, drugs, medication supplies and hazardous substances must be securely locked. Controlled substances are locked at all times. Emergency medical equipment: During business hours providers are prepared to provide emergency services for management of emergency medical conditions that occur on site until the emergent situation is stabilized and/or treatment is initiated by the local 9 Emergency Medical Service (EMS) system. I:\QUALITY\External Website\FSR\FSR\Behavioral Health-Substance Abuse Site Review Guidelines.doc Page 8 of 8